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1

Normal range for albumin

3.5-5.5g/dL
35-55g/L

2

To find out about drug interactions choose the SINGLE most appropriate database from the list: -

•Cochrane database
•Medline
•National institute for clinical excellence (NICE) website
•British National Formulary
•BMA website
•Evidence-based medicine website
•BMJ website

British National Formulary


The BNF will tell you about indications and contraindications for drugs

3

50 yr old housewife presents with parities and jaundice with pale stools, dark urine and steatorrhoea, pigmentation and xanthelasma. Examination reveals splenomegaly. Anti-mitochondrial antibodies are present

Primary biliary cirrhosis
PBC is chronic where intrahepatic small bile ducts are progressively damaged (then lost) occurring on background of portal tract inflammation. Fibrosis develops leading to cirrhosis. believed to be autoimmune (most have AMA)

3

65 year old ex-smoker is deeply jaundiced. He has epigastric pain radiating to his back. A dilated gall bladder is palpable and there is hepatomegaly. He has lost about 5kg in weight

Carcinoma of the pancreas
Head of pancreas cancer presents with painless obstructive jaundice and weight loss and presents late. There is epigastric pain here which is possible. Whipple's procedure or Traverso-Longmire procedure (pancreaticoduodenectomy)only cure. tumour marker for pancreatic cancer is CA19-9 which is useful in pre-op staging

5

A 23 year old male was upset England lost a penalty shoot-out and decided to kick a wall in a construction site on the way home. The wall fell on him and he was crushed. It took paramedics a long time to retrieve him from the rubble. His leg is swollen and tender. Urine specimen has a dark red appearance.

Rhabdomyolysis

This is a crush injury that has caused myocyte lysis – rhabdomyolysis. The diagnosis would be confirmed by raised CK. The swelling and pain in his leg muscle is a further give away. The dark urine here is caused by urinary myoglobin. The long time it took for him to be retrieved is also an indication of this diagnosis. The mainstay of treatment is with fluid hydration.

6

A 22 year old man comes to see you on his return from a holiday in Spain. He has a 3-4 day history of fever, malaise, nausea, vomiting and abdominal discomfort. He is noticeably jaundiced with dark urine and pale stools. there is also tender hepatomegaly on examination. he wonders if this is related to his meal of shellfish from a street vendor

Hepatitis
Likely to be hep A which is primarily transmitted via faecal-oral route. after virus is consumed and absorbed it replicated in liver and is excreted in bile. transmission precedes symptoms by 2 weeks and patients are non-infectious 1 week after onset of jaundice. risk factors include living in endemic area, contact with infected person, homosexual sex or known food-borne outbreak, SHELLFISH

6

A 6 year old Black boy presents with mild jaundice and some pain and swelling of his fingers. O/E you note splenomegaly

Sickle Cell anaemia

Africans have higher incidence of SC anaemia. here there is bone pain with dactylics, consistent with hand-foot syndrome which can be what young infants and kids present with. jaundice is due to haemolysis

7

A 35-year-old overweight woman complained of severe abdominal pain and vomiting. She had had a previous attack when on holiday and had had to be flown home as a medical emergency. She looks jaundiced and in distress.

Pancreatitis

8

A 47-year-old male policeman was brought to A&E having become SOB suddenly. He now complains of palpitations, which he has never experienced before. Heart sounds are irregular but no murmurs are audible. He is a diabetic with hypertension.

Atrial Fibrillation

9

Match the cause of hypotension to the following case history:

76-year-old woman was admitted with confusion. She had been increasingly unable to care for herself. On admission, she was found to have cool peripheries and her blood pressure was 100/70. Blood results showed plasma urea 25 mmol/L and plasma creatinine 120 μmol/L.

Volume depletion


Volume depletion is a reduction in ECF volume due to salt and fluid losses which exceed intake. Causes include vomiting, bleeding, diarrhoea, diuresis and third space losses. Symptoms do not occur until large losses have alrady occured. Cool peripheries are a sign of peripheral shut down. Confusion may reflect poor cerebral flow or uraemia.Volume depletion has led to the low BP. Other symptoms include postural hypotension and tachycardia, weight loss and signs of shock. Serum urea and creatinine is elevated (you need to eyeball the patient when looking at creatinine – a very big body builder will have a much higher creatinine), indicating poor renal blood flow. This patient needs IV saline fluid replacement.

10

Match the cause of hypotension to the following case history:

22-year-old man presented with vomiting. He had not been feeling himself for some weeks. On examination, the skin creases of his hands were dark. Blood results showed plasma urea 8.5mmol/L, sodium 121 mmol/L and potassium 5.1 mmol/L.

Hypoadrenalism


Hyperpigmentation in the palmar creases points towards Addison’s disease. Hyperpigmentation due to excess ACTH production can be mucosal or cutaneous and is more pronounced in the palms, knuckles and around scars. MSH is a byproduct of the production of ACTH from the cleavage of POMC. Sodium is low and potassium elevated. Vomiting is present in 75% of patients and nausea is a common finding. Additionally, postural hypotension may be present. The presence of other autoimmune diseases is also a risk factor for the development of Addison’s.

11

Match the cause of hypotension to the following case history:

45-year-old man presented with severe chest pain radiating down his left arm. He was pale, cold and sweaty. BP was 80/50 mmHg, pulse rate was 100 and regular. JVP was raised by 3cm and auscultation of his chest revealed basal creps. Over the next few hours, he became progressively short of breath despite being given IV diuretics. Chest x-ray showed signs of pulmonary congestion

Cardiogenic shock


Cardiogenic shock is pump dysfunction. This may occur, like in this case, after MI (shock complicates just under 10% of MIs) or may be due to cardiomyopathy, valve dysfunction or arrhythmias. This cause of shock in this patient is obviously apparent. Clinical signs of shock include stress responses of tachycardia and tachypnoea, hypotension (

12

Match the cause of hypotension to the following case history:

67-year-old man was observed to be very drowsy 12 hours after an aortic aneurysm repair. There had been considerable blood loss and he had been given 4 units of blood during surgery. He had been written up for pethidine 50-100 mg 3 hourly postoperatively and had had 3 doses. BP had been 150/80 post-op and was now 100/60 with a pulse rate of 75/min. O2 saturation was low at 85%.

Drug induced


Opioid OD symptoms include CNS depression (drowsiness, sleepiness), respiratory depression and relative bradycardia. This patient needs ventilation prior to the administration of naloxone, titrated to patient response.

15

To find systematic reviews of literature choose the SINGLE most appropriate database from the list: -

•Cochrane database
•Medline
•National institute for clinical excellence (NICE) website
•British National Formulary
•BMA website
•Evidence-based medicine website
•BMJ website

Cochrane database


The Cochrane database was established by the NHS with the aim of being a place to review existing literature on a subject matter.

16

To find original research articles choose the SINGLE most appropriate database from the list: -

•Cochrane database
•Medline
•National institute for clinical excellence (NICE) website
•British National Formulary
•BMA website
•Evidence-based medicine website
•BMJ website

Medline


Medline, or pubmed, is run by the US Government and will help you search through many journals with keywords to look for new and older research on a matter

17

To find disease management guidelines choose the SINGLE most appropriate database from the list: -

•Cochrane database
•Medline
•National institute for clinical excellence (NICE) website
•British National Formulary
•BMA website
•Evidence-based medicine website
•BMJ website

National institute for clinical excellence (NICE) website


In the UK, NICE currently analyses the medical and cost-effectiveness of various treatment options and publishes guidelines based upon this

18

To find out about drug use in the lactating mother choose the SINGLE most appropriate database from the list: -

•Cochrane database
•Medline
•National institute for clinical excellence (NICE) website
•British National Formulary
•BMA website
•Evidence-based medicine website
•BMJ website

British National Formulary


The BNF will tell you about indications and contraindications for drugs

19

25yr old man presents to you with an incidental finding of raised bilirubin (31umol). no other signs of liver disease are present. Further investigations show raised unconjugated bilirubin. When asked he tells you that other family members have suffered jaundice

Gilbert's Syndrome
occur in asymptomatic patients as incidental finding/mild jaundice in adolescence. high unconj BR other liver tests normal. blood smear normal, normal reticulocyte count, normal Hb showing not due to haemolysis. no treatment needed, condition due to low UDPGT activity causing low conjugation of unconj bilirubin so high levels. positive FH common, as autosomal recessive

19

Choose the SINGLE test from the list that would be of most help in establishing a diagnosis of aortic dissection.

A. CT head
B. MRI head
C. CT chest, abdomen and pelvis
D. Trans-thoracic echocardiography
E. Ventilation-perfusion scan
F. D-dimer
G. Duplex ultrasound
H. Upper GI endoscopy
I. Barium enema
J. Renal function tests
K. Barium swallow

CT chest, abdomen and pelvis


Dissecting aneurysms are either type A, which involves the ascending aorta, or type B. Type A dissections require urgent surgery whereas type B can be managed medically if it is not complicated by end organ ischaemia. A CT scan is indicated as soon as a diagnosis of aortic dissection is suspected and should be from the chest to the pelvis to see the full extent of the dissecting aneurysm. What you will see is the intimal flap. MRI is more sensitive and specific but is more difficult to obtain acutely.

20

Choose the SINGLE test from the list that would be of most help in establishing a diagnosis of pituitary tumour.

A. CT head
B. MRI head
C. CT chest, abdomen and pelvis
D. Trans-thoracic echocardiography
E. Ventilation-perfusion scan
F. D-dimer
G. Duplex ultrasound
H. Upper GI endoscopy
I. Barium enema
J. Renal function tests
K. Barium swallow

MRI head


Pituitary MRI is preferred over CT and you will be able to see if the tumour has invaded, for example, the sphenoid sinus and cavernous sinuses or any compression of the optic chiasma. MRI is contra-indictaed in some cases such as those with a permanent pacemaker or those with ESRF on dialysis – in which case you would perform a CT. Both are done with contrast enhancement. A sellar mass will be seen.

21

Choose the SINGLE test from the list that would be of most help in establishing a diagnosis of renal artery stenosis.

A. CT head
B. MRI head
C. CT chest, abdomen and pelvis
D. Trans-thoracic echocardiography
E. Ventilation-perfusion scan
F. D-dimer
G. Duplex ultrasound
H. Upper GI endoscopy
I. Barium enema
J. Renal function tests
K. Barium swallow

Duplex ultrasound


Renal artery stenosis is basically narrowing of the renal artery. There may not be any clinical consequences of this – just because someone’s renal arteries are narrowed does not mean they are suffering worsening kidney function, although this may be the case, especially after blockade of the renin-angiotensin system, and patients may have difficult to control and accelerated hypertension. A definitive diagnosis is made on imaging, where there is some controversy on what is most appropriate to use. USS is safe and non-invasive but the sensitivity and specificity is low. CT/MR angiography has the risk of contrast nephropathy and nephrogenic systemic fibrosis. Conventional angiography (the best test available) has the risk of bleeding and emboli as well as contrast related risks already mentioned.

Generally, the recommendation is to start with renal duplex ultrasound. This would not be an unreasonable approach. This can be followed by further tests. Although, in some centres in the country, the first line is CT or MR angiography and duplex USS is only done if there is a contra-indication to CT/MR angiography. However, the only reasonable option on this list is duplex USS.

22

A 45 year old man presents with sudden onset epigastric pain, constant in nature. He has had several previous episodes. He drinks half a bottle of whiskey per day. what does he have?

Acute pancreatitis

23

Choose the SINGLE test from the list that would be of most help in establishing a diagnosis of pulmonary embolism.

A. CT head
B. MRI head
C. CT chest, abdomen and pelvis
D. Trans-thoracic echocardiography
E. Ventilation-perfusion scan
F. D-dimer
G. Duplex ultrasound
H. Upper GI endoscopy
I. Barium enema
J. Renal function tests
K. Barium swallow

Ventilation-perfusion scan


The first line recommended initial imaging test is a CT chest to directly visualise the thrombus in a pulmonary artery, which would show as a filling defect. However this option is not given in this list and the test to pick here is a V/Q scan, which offers a similarly high level of sensitivity and specificity. In a PE the area affected will be ventilated but not perfused.

24

A 58 year old man who is recently diagnosed with lung cancer has started chemotherapy and radiotherapy. He complains of a fever, weight loss and fatigue. There are swollen lymph nodes and tetany. Serum potassium is elevated and calcium is low.

Tumour lysis syndrome


There is recent diagnosis of malignancy here combined with the recent start of both chemotherapy and radiotherapy. This is tumour lysis syndrome which encompasses metabolic and electrolyte abnormalities, like hyperkalaemia, occuring after cytotoxic treatment in a patient with cancer. There is excessive cell lysis and the release of intracellular contents into the bloodstream leads to elevated levels of serum urate, potassium, phosphate and a reduction in calcium level.

25

A 72 year old woman is being treated for a diabetic foot ulcer and is afraid she may need an amputation. Serum potassium today is markedly elevated. Results over the past week have been normal. You find out the 2nd year medical student had some difficulty drawing the blood.

Pseudohyperkalaemia


This is pseudohyperkalaemia caused by haemolysis of the sample. The medical student who has had some difficulty drawing the blood has haemolysed the sample. Potassium in serum will in this case exceed the plasma value by >0.5 mmol/L and the pink tinge when centrifuging the sample will also give this away.

26

A 28 year old male presents with increased skin pigmentation, vitiligo, postural hypotension and raised potassium. Urine potassium is low. He has also lost some weight.

Addison’s disease


Hyperpigmentation is due to excess ACTH production and can be mucosal or cutaneous and is more pronounced in the palms, knuckles and around scars. MSH is a byproduct of the production of ACTH from the cleavage of POMC. Sodium is low and potassium elevated in this condition. Additionally, postural hypotension may be present. The presence of other autoimmune diseases is a risk factor for the development of Addison’s, such as this man’s vitiligo. Diagnosis of Addison’s can be made on an ACTH stimulation test (synacthen test) whereby serum cortisol remains low despite the administration of synthetic ACTH. In an emergency, treatment should not be delayed by diagnostic testing.

27

A 16 year old diabetic has been trying to lose weight. She presents at with a vomiting, postural hypotension and abdominal pain. She insists she has been taking her insulin regularly and does not use illicit drugs. Serum potassium is elevated.

DKA


Hyperpigmentation is due to excess ACTH production and can be mucosal or cutaneous and is more pronounced in the palms, knuckles and around scars. MSH is a byproduct of the production of ACTH from the cleavage of POMC. Sodium is low and potassium elevated in this condition. Additionally, postural hypotension may be present. The presence of other autoimmune diseases is a risk factor for the development of Addison’s, such as this man’s vitiligo. Diagnosis of Addison’s can be made on an ACTH stimulation test (synacthen test) whereby serum cortisol remains low despite the administration of synthetic ACTH. In an emergency, treatment should not be delayed by diagnostic testing.

28

A 65-year-old man with a six-month history of ischaemic heart disease on Aspirin presents with a one-month history of epigastric pain and two days of dark stools. He has vomited a ‘cupful’ of fresh blood this morning.

Choose the SINGLE most appropriate diagnostic investigation from the list: -

A. H.pylori breath test
B. Colonoscopy
C. Chest x-ray
D. Liver biopsy
E. Full blood count
F. CT scan abdomen
G. Upper GI endoscopy
H. Liver function test
I. Barium swallow
J. Upper GI endoscopy
K. Clotting profile

Upper GI endoscopy


NSAID use is a key risk factor for a peptic ulcer. Other key risks include H. pylori infection, smoking and FH of PUD. Zollinger-Ellison syndrome should be considered if there are multiple ulcers or ulcers refractory to treatment. The epigastric pain and symptoms of dark stools are consistent with a bleeding peptic ulcer. The most specific and sensitive test is an upper GI endoscopy which also allows management of the bleed. A biopsy may also be done to rule out malignant transformation. Gastric ulcers require a compulsory biopsy but duodenal ulcers rarely undergo malignant change. Management here can be aimed at discontinuing NSAIDs which are the cause in this case.

29

A 32-year-old man attends your surgery saying he brought up blood every morning for the last week. He is unsure whether he is vomiting or coughing it up. His haemoglobin (done yesterday) is 14 g/dL.

Choose the SINGLE most appropriate diagnostic investigation from the list: -

A. H.pylori breath test
B. Colonoscopy
C. Chest x-ray
D. Liver biopsy
E. Full blood count
F. CT scan abdomen
G. Upper GI endoscopy
H. Liver function test
I. Barium swallow
J. Upper GI endoscopy
K. Clotting profile

Chest x-ray


The blood being brought up here occurs at a fixed time period every day and he is not anaemic. This makes you suspect a respiratory cause of his haemoptysis such as pneumonia – particularly TB, cancer, vasculitis like Wegener’s, bronchiectasis and bronchitis.

30

A 55- year-old lady on Warfarin for recurrent pulmonary emboli presents having vomited a small amount of blood that morning. She has been on antibiotics for a presumed chest infection for the last week.

Choose the SINGLE most appropriate diagnostic investigation from the list: -

A. H.pylori breath test
B. Colonoscopy
C. Chest x-ray
D. Liver biopsy
E. Full blood count
F. CT scan abdomen
G. Upper GI endoscopy
H. Liver function test
I. Barium swallow
J. Upper GI endoscopy
K. Clotting profile

Clotting profile


This woman is on prophylactic warfarin anticoagulation. There is an interaction here with the antibiotics this woman is taking which has resulting in enhanced anticoagulation effects of warfarin, causing her to bring up the blood. Cepahalosporins, chloramphenicol, ciprofloxacin, clarithryomycin, erythromycin and metronidazole are all examples which increase the effect of warfarin. Any P450 inducer will have this effect as warfarin is a drug metabolised by cytochrome P450 enzymes. Antibiotics can also upset the gut flora which reduces vitamin K levels.